2. PHYSIS
• Physis is a highly organized,
yet dynamic structure that
consists of chondrocytes
undergoing proliferation,
differentiation, and formation
of complex extracellular
matrix.
• Histologically, the physis is
divided into four zones
oriented from the epiphysis to
the metaphysis: Germinal
(reserve), proliferative,
hypertrophic, and provisional
calcification
3. PHYSEAL INJURIES
• The most frequent mechanism of injury is fracture.
• Other mechanisms of injuries to the physis includes
Infection,
Disruption by tumor,
Cysts and
Tumor-like disorders,
Vascular insult,
Repetitive stress,
Irradiation and other rare etiologies
4. SALTER HARRIS CLASSIFICATION OF
PHYSEAL FRACTURESTYPE-I
• Salter–Harris type I injuries are
characterized by a transphyseal plane of
injury, with no bony fracture line through
either the metaphysis or the epiphysis.
5. • Because the
hypertrophic zone is the
weakest zone
structurally, separation
occurs at this level.
• The general principles
of fracture management
are to secure a gentle
and adequate
reduction of the
epiphysis on the
metaphysis and
stabilize the fragments
as needed.
6. TYPE- II
• The fracture extends from the physis into the periphery of the
metaphysis.
7. • Similar to type I injuries, the articular surface is not
affected and the general principles of fracture
management are effectively the same
8. TYPE-III
• The fracture plane extends from the physis into the epiphysis
and articular surface.
9. • Thus, Anatomic reduction (usually open) and
stabilization are required to restore the articular
surface and to minimize the potential for growth
disturbance.
10. This fracture pattern is important for two main reasons:
-the articular surface is involved and the fracture line involves
the germinal and proliferative layers of the physis.
11. TYPE-IV
• Type IV fractures are effectively vertical shear fractures,
extending from the articular surface to the metaphysis
12. TYPE-V
• Salter and Harris postulated that type V fractures represented
unrecognized compression injuries with normal initial
radiographs that later produced premature physeal closure.
• Type-v fracture usually is diagnosed only in retrospect when a
growth disturbance develops
13. INVESTIGATIONS
Modalities available for the evaluation of physeal injuries include
• plain radiographs,
• CT scans,
• MRI scans,
• Arthrography and
• Ultrasonography.
14. Treatment of Physeal Fractures
• Fractures in children, including physeal injuries, heal more
rapidly than in adults, and they are less likely to experience
morbidity or mortality from prolonged immobilization.
• Salter–Harris type I and II fractures, have minimal risk of growth
disturbance and excellent remodeling potential in most patients.
• Generally, SH type 1 & 2 injuries can be treated with closed
reduction and casting or splinting and then re-examination in 7-
10 days to evaluate maintenance of the reduction
15. • Intra-articular fractures (such as Salter–Harris types III and IV)
require anatomic reduction to restore the articular surface and
prevent epiphyseal– metaphyseal cross union.
• All type 3 & 4 fractures treated by INTERNAL FIXATION
regardless of the amount of displacement
• In type 5 fractures, cartilage cells of the physis are crushed, and
regardless of the form of treatment, Growth disturbance can
occur.
• Displaced injuries require reduction (within 48hrs) because
arrest is common after late reduction
16. • In such patients, the surgeon must be cautious not to create
physeal injury by excessive force or invasive reductions
• When performing a closed reduction of physeal fractures the
aphorism “90% traction, 10% translation” is useful to minimize
iatrogenic injury to the physis which may occur as a physis
grinds against a sharp bony metaphysis.
• Remanipulation of physeal injuries should not be attempted
after 5 to 7 days
17. FRACTURE HEALING
• Fractures through the physis heal faster than through the bone,
usually within 2 to 4 weeks.
• The growth plate heals by
1) Increased endochondral bone and cartilage formation, and
2) Gradual reinvasion by the disrupted metaphyseal vessels.
• Depending on the level of injury within the physis, different
types of chondro-osseous healing may occur.
18. When fracture occurs through hypertrophic
chondrocytes
Healing occurs by ---Continued, relatively rapid
increase in number of cells within the coloumns
of hypertrophic chondrocytes
Moderate widening of the physis
19. Fracture in hypertrophic layer
Seperation of tissue– Gap
Filled by haemorrhage and fibroblastic tissue
Progressively forms Disorganized cartilage tissue
Widening of physis
20. Injury to all cell layers of the physis
Fibrous tissue fills the gap between separated physeal layers
• The larger the gap filled with fibrous tissue and the larger the
time from fracture to skeletal maturity
21. COMPLICATIONS OF PHYSEAL
INJURIES
• Neurovascular compromise and compartment syndrome
represent the most serious potential complications.
• The one complication unique to physeal injuries is growth
disturbance that may produce angular deformity or shortening
